Citation Nr: 21003380 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 15-14 971 DATE: January 21, 2021 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Marine Corps from December 1973 to December 1975. He has additional service in the United States Marine Corps Reserves. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned at a hearing in March 2017. The Board remanded this matter in July 2018 and August 2020 for additional development. The matter is now returned to the Board for further appellate review. Unfortunately, another remand is necessary. VA provided the Veteran an examination in October 2020 to determine the nature and etiology of the Veteran’s lumbar spine disability. The examiner concluded the Veteran’s lumbar spine disability was less likely than not incurred in or caused by the claimed in-service lumbar strain. Rather, the examiner reasoned the Veteran’s retrolisthesis and degenerative arthritis of the spine were more likely due to aging because there is no recorded injury occurring in service. The medical opinion is insufficient because it does not adequately explain why the Veteran’s current lumbar disability is more likely due to aging than the documented in-service lumbar strain and because the examiner impermissibly dismissed the Veteran's lay reports of continuous lower back problems solely because these complaints were not documented in medical treatment records. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician (other than the clinician who provided the October 2020 opinion) to determine whether the Veteran’s lumbar spine disability is related to the Veteran’s military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Please note, if the examiner deems it reasonable, an alternate format such as a telehealth interview is acceptable. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s lumbar spine disability began in or is otherwise caused by the Veteran's active service, to include his documented in-service lumbar strain. The clinician should address the Veteran’s lay statements regarding falling with a full backpack onto his rifle while rucking up a mountain and immediately feeling pain in his back, hips, and legs. These contentions may not be dismissed by the clinician solely because they are not documented in the Veteran’s service treatment records. The examiner should address any other pertinent evidence of record. If the examiner determines that the Veteran’s current lumbar spine disability is related to aging, the examiner must explain why the lumbar spine disability would be more likely due to aging than the in-service injuries described by the Veteran. This explanation must be supported by a rationale that goes beyond simply noting that a specific in-service injury is not documented in treatment records. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Zachery S.C. Luce, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.